SAMHSA Technical Experts Meeting: Themes Parallel Traumatic Stress Institute Change Model to TIC

The research team of the Traumatic Stress Institute (TSI) of Klingberg Family Centers was honored to participate in SAMHSA’s recent national technical experts meeting titled Developing a Measurement Strategy and Metrics for Trauma-Informed Change in Behavioral and Health Settings.  Dr. Steve Brown and Pat Wilcox from TSI and Dr. Courtney Baker from Tulane University attended the meeting.

 The gathering brought together experts and funders from across the US who are implementing and evaluating trauma-informed care in a variety of sectors. There were representatives of mental health, primary care medicine, HIV/AIDS care, ACE/Resilience state and local initiatives, schools, consumer-run support agencies, and others. TSI was invited, in part, because of its pioneering measure of professional  attitudes related to TIC, the ARTIC Scale, one of the first psychometrically valid measures of TIC.

 TSI’s mission is to foster the transformation of organizations and service systems to TIC through the delivery of whole-system consultation, professional training, coaching, and research. Recently, we refined our TSI Whole-System Change Model , a 12-18 month intensive training and consultation intervention for organizations making TIC culture change. 

The revision stems from the awareness, confirmed at the SAMHSA meeting, that despite the tidal wave of funding and interest in TIC implementation, there is very little empirical evidence of TIC’s efficacy to change outcomes (Hanson & Lang, 2016).  A working hypothesis about a factor explaining this is that the “dosage” of TIC implementation in most settings is too small and not targeted enough to bring about consistent outcomes at the provider or patient/client/consumer level.  

We were pleased that many of the themes of the SAMHSA meeting (highlighted in bold below) were consistent with both the longstanding pillars of our model and the changes recently made. Here are some examples.  

1. For an organization to begin the paradigm shift and sustain the momentum through the developmental steps to trauma-informed care (Missouri Department of Mental Health and Partners, 2014), they must embed the change in the very fabric of their system. This process often takes 3-5 years or more.

For this reason, the TSI Model includes intensive work up front involving, among other things, the Risking Connection (RC) Trauma Training Program which is sustained through a Train-the-Trainer method of dissemination. Organizations maintain expertise for years to come after consultants leave through a cadre of credentialed RC Trainers and Champions that benefit from credentialing, recertification, and ongoing professional enrichment.  

1. For effectiveness and cost efficiency, TIC implementers must seek to identify which of SAMHSA’s 10 implementation domains (SAMHSA, 2014) are MOST likely to drive change and prioritize those domains first. This may depend on the kind of organization and what sector the organization is in, but some domains are likely more critical than others. The TSI Model prioritizes five of the SAMHSA domains:

Governance and Leadership – system change simply will not work without the full buy-in at the highest level of the organization. We work with executive leadership (including Board of Directors) and a TIC Organizational Task Force from the outset to ensure and rally system-wide support.

Financing – a critical indicator of whole system buy-in is allocation of the financial and human resources required to make TIC change.

Engagement and Involvement of consumer survivors/people with lived experience – people with lived experience of trauma must have voice in what truly makes a difference in their lives and are a vital check to counter the “blind spots” of TIC implementers. An advisory panel including numerous consumer survivors was an integral part of the creation of the Risking Connection trauma curriculum and training program.

Workforce Development – training of all staff using a vetted standardized training model such as Risking Connection provides a common philosophy, a common theoretical framework, and common language. We have years of empirical evidence that foundational RC training results in knowledge change and more favorable staff attitudes toward TIC which we believe drives behavior change.

Progress Monitoring – as we state below, data monitoring ensure implementation is on track and also sustains energy for continued implementation.

1. Consistent with the tenets of implementation science, ongoing coaching is critical to a change in TIC practice at the patient/client/consumer level.

The TSI Model provides monthly coaching to the TIC Organizational Task Force throughout the implementation process.

1. Data collection not only measures outcomes, but it also drives the implementation process. When data is collected and fed back to the organization in a timely way, key stakeholders see concrete outcomes of their work, make course corrections, and gain motivation to keep up the implementation and even push for deeper change.

The TSI model includes data collection on multiple measures (including the ARTIC Scale) as well as outcome metrics (ie. staff turnover, discharge status, restraints et al). Both individual staff and the organization receive timely feedback on their change in scores via an online dashboard. This allows them to make data-informed decisions in an ongoing way.

While the science of TIC implementation and measurement strategies is in its infancy, the recent SAMSHA meeting provided a generative space for thought leaders to begin charting a more cohesive research agenda for the TIC field. As we spread the message about the impact of trauma and adversity on public health, we ALL have a stake in seeing science catch up with practice. TSI is grateful to be part of charting that future and is dedicated to advancing the TIC field.